The most competent professional in any field is bound to slip up someday, as to err is human. But for medical professionals prescribing and dispensing medication, the consequences for any slip-up can be fatal.
There are many factors that can cause medication errors (ME). These can be broken down into knowledge-based errors and execution-based errors. Knowledge-based errors arise when clinicians are not equipped with the latest drug knowledge. Busy clinicians find it hard to keep up with the rapidly evolving usage or dosage indications, or keep track of the type of drugs available in their hospital’s formulary. On the other hand, execution-based errors include communication barriers caused by verbal miscommunication, illegible written orders, or ‘look-alike sound-alike’ drug names. They also include administrative lapses where wrong patient names are noted, or misreading of medication labels by staff. Specifically in ASEAN, a 2015 review of existing ME data highlighted that common ME causes in the region included staff shortage/high workload and lack of knowledge or experience.
Technology, in the form of clinical decision support system (CDSS), has risen as a solution for Asian hospitals to reduce such preventable errors. The CDSS market in Asia-Pacific is projected to witness exponential CAGR of more than 12% over the period of 2017-2025. This could be attributed to a large base of clinics and hospitals, a growing silver generation, and rising adoption of digital technologies in the region’s clinical practices. More importantly, the COVID-19 pandemic has triggered a strong uptake for evidence-based clinical information. For example, the COVID-19 content topics from Wolters Kluwer UptoDate and Lexicomp were used more than 18 million times (out of which a significant number are from Asia-Pacific).
Rise of the Machines
Drug screening systems are becoming key allies in the fight against medication errors. They work by alerting clinicians at the point-of-care, by screening drug data such as dosage, drug interactions, allergies, and duplicate therapies. These tools are designed to work within the clinical workflow, integrating with other clinical systems to improve safety and outcomes.
This strategy of embedding drug screening functionality within the hospital’s IT systems such as Electronic Medical Records (EMRs) and pharmacy systems, has enabled clinicians to screen for causes of adverse drug events within their workflow, leading to better patient outcomes.
Medi-span Clinical, a leading drug screening solution from Wolters Kluwer Health, has been deployed in several hospitals in Singapore, Indonesia, Taiwan, the Philippines and Australia. Medi-span Clinical supports the clinicians with actionable drug data and insights, enabling better prescribing and dosing decisions based on the latest clinical evidence.
By integrating Medi-span Clinical drug database and clinical screening modules with their hospitals’ EMR and formularies, hospitals have access to an extensive library of drug information, covering medication names, dosages, strengths, and industry-standard codes such as SNOMED and ICD-10.
“There is a strong demand for an integrated knowledge repository that can be used while planning for diagnosis and treatment,” said Dr Hyunseon Park, Director of Information Strategy Planning Department and Professor in Neurosurgery of Inha University Hospital in Korea.
Medi-span Clinical drug screening modules are sophisticated and highly customisable. The core screening functions include screening for drug allergies, interactions, dose screening, drug orders and duplicate therapies. Hospitals can also implement advanced screening functionalities including contraindications by route of administration, contraindications associated to drug use based on patient gender, age, pregnancy and lactation, and drug-disease contraindications.
Extensive clinical content based on evidence
Mr Wu Nai-Chun, Director of Pharmacy at YeeZen General Hospital in Taiwan, noted that this has helped his colleagues avert potential errors. “When Medi-span Clinical displays an alert in the EHR, the physician can first check the reason for the alert and decide whether to change the prescription.”
A good CDSS also helps clinicians keep current with their practice, in the face of new medical data and trends. Medi-span Clinical maintains a constantly updated database of medical information – from new medications to recent advisories of drug interactions – ensuring that clinicians are always working with the latest evidence-based information.
This is not a simple task. Today, clinicians are faced with a mind-blowing volume of research that is constantly being updated as new evidence emerge. COVID-19 has expanded the need for reliable information, at a higher sense of urgency. The process is supported by a drug information editorial team of more than 150 specialists trained in advanced clinical disciplines and extensive clinical experience, as well as over 260 consultants in specific subspecialty expertise. The editorial team follows a rigorous process that seeks to balance the timely review and interpretation of new information, providing users with trusted recommendation and prompt access.
“The speed of Medi-span Clinical database update is faster than manual updates by pharmacists in the past,” said Dr Chen Hui Yu, Director of Pharmacy at Taiwan’s Chang Gung Memorial Hospital (CGMH). She raised the ability to provide personalised dosing recommendations as another benefit of Medi-span Clinical. The solution intelligently processes patient data and provides recommendations based on the patient’s profile, such as age, gender and comorbidities. This has proved helpful for CGMH’s clinicians particularly in their care for seniors. “Before introducing Medi-span Clinical, CGMH did not have a system to support medication screening for geriatric patients. After deployment, geriatric dosing knowledge has improved significantly,” said Dr Chen.
Clinicians at YeeZen are currently using both Medi-span Clinical and Lexicomp, Wolters Kluwer’s referential drug solution, in their day-to-day care decisions. Mr Wu said that both solutions complement each other. “Medi-span Clinical provides automatic detection of medication errors and Lexicomp provides evidence-based information for physicians and pharmacists to make decisions in clinical practice. Overall, I believe it helps to reduce some medication errors.”
Imparting to the next generation of clinicians
Besides the clinical setting, Medi-span Clinical and UpToDate (another CDSS resource) have also been used in the training of medical students. Dr Park of Inha noted that the solutions are trusted aides for both its clinicians and teachers. “Under the vision of “Think Safety, Build Value”, Inha University Hospital puts patient safety first and strives to create hospital values,” he said. “About 97.5% of specialists and teachers at Inha University Hospital use UpToDate every day.”
CGMH’s Dr Chen has also found Medi-span Clinical useful in guiding novice clinicians. “It has helped raise the ability of new pharmacists to review prescription orders,” she said.
Reducing Alert Fatigue
While automated drug screening solutions are useful in providing timely warnings and interventions in potentially unsafe situations, clinicians are facing an unexpected challenge. And this has brought about new threats to patient safety. Alert fatigue, where clinicians are flooded with alerts from their IT systems, can overwhelm clinicians’ decision making ability. Quite simply, clinicians bombarded with large volumes of safety alerts (both meaningless and critical) become desensitised to them. The flood of alerts – which were aimed at improving safety – then become a risk to patient safety instead, when clinicians ignore the critical ones and fail to react to potential errors or severe patient harm.
The solution lies in having a notification system which increases alert specificity based on severity and clinical consequentiality. Furthermore, computer-human interface principles (such as format, content and colour) should be applied to the systems, to design more effective alerts that work best for the end-user clinicians.
Medi-span Clinical alert control functionality can be implemented by site, department and even individual end-user. This allows for dynamic customisation of alert filters at various level. For example, an individual clinician may be allowed to turn off an alert with a simple “Don’t show me this alert again” or “Don’t show me this alert again for this patient”. Certain specialties such as Oncology, may choose to suppress all but the most severe alerts.
Additionally, Medi-span Clinical employs contextual alerting content, taking the patient’s known health condition, and factoring in the patient’s weight, age, renal function, to provide the most relevant alerts.
This balanced approach aims to improve the effectiveness and usefulness of alert screening and management.
Closed-Loop medication management and HIMSS Level 7 validation
A closed-loop medication management system is one that, through automation, eliminates the possibility of errors throughout the medication cycle: from the doctor’s prescription, to the pharmacist’s validation, to the nurse’s issuance of the medication. Having this system in place is a key requirement in meeting the Healthcare Information Management and Systems Society (HIMSS) electronic case adoption model (EMRAM) certification, where the maximum Level 7 is awarded to hospitals which have reached highest level of maturity in their EMR capabilities, closed loop management of medical operations, and other technologies to optimise patient care.
For China Medical University Hospital (CMUH), the introduction of Medi-span Clinical has assisted them to achieve Level 7 certification, said Dr. Bai Peiying, CMUH’s Director of General Internal Medicine, Chairman of the Medical Committee and Deputy Director of the Teaching Department. Dr Bai affirmed that Medi-span Clinical is a complete drug warning system that is data-rich, fully functional and meets the full set of HIMSS requirements. Though the hospital had considered building their own system, the complexity of such systems, coupled with shortage of IT staff and busy clinician schedules, meant that going in-house was not feasible.
“Medi-span Clinical is the best solution to meet the original plan framework, ” Dr Bai said. “Including drug-to-drug interactions, drug-to-food, and drug allergies, the Medi-span Clinical database has fairly complete information from around the world, and a dedicated editorial team responsible for data collection and collation review, as well as system updates, features that local hospitals with limited IT and clinical resources cannot match.”
Future of technology in supporting clinical decisions
While CDSS have proved to be an effective tool in reducing ME, they will need to be continually updated and improved, to respond to the fast-changing medical landscape and feedback from the hospitals and end-users. For Medi-span Clinical, for example, Mr Wu of YeeZen suggested that capturing more integrated usage statistics would be useful for tracking by hospital management. “Medi-span Clinical usage reports or statistics can be linked to the prescribing behaviour of physicians, to assist the hospital management to determine whether the prescribing behaviour of physicians has changed as a result of the Medi-span Clinical alerts.”
As they continue to evolve to meet the needs of hospitals and physicians, Medi-span Clinical and other clinical decision support technologies are set to help Asian hospitals safeguard patient safety, through lowering the risk of medication errors and preventable patient harm.